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The novel coronavirus disease 2019 (COVID-19) pandemic is a global crisis, challenging healthcare systems worldwide. Many patients present with a remarkable disconnect in rest between profound hypoxemia yet without proportional signs of respiratory distress (i.e. happy hypoxemia) and rapid deterioration can occur. This particular clinical presentation in COVID-19 patients contrasts with the experience of physicians usually treating critically ill patients in respiratory failure and ensuring timely referral to the intensive care unit can, therefore, be challenging. A thorough understanding of the pathophysiological determinants of respiratory drive and hypoxemia may promote a more complete comprehension of a patient’s clinical presentation and management. Preserved oxygen saturation despite low partial pressure of oxygen in arterial blood samples occur, due to leftward shift of the oxyhemoglobin dissociation curve induced by hypoxemia-driven hyperventilation as well as possible direct viral interactions with hemoglobin. Ventilation-perfusion mismatch, ranging from shunts to alveolar dead space ventilation, is the central hallmark and offers various therapeutic targets.

This paper proposes a mathematical framework for understanding how the structural changes in the COPD lung reflect in model parameters. The core of the analysis is a correlation between the heterogeneity in the lung as COPD degree changes (GOLD II, III and IV) and the nonlinearity index evaluated using the forced oscillation technique. A low frequency evaluation of respiratory impedance models and nonlinearity degree is performed since changes in tissue mechanics are related to viscoelastic properties. Simulation analysis of our model indicates a good correlation to expected changes in heterogeneity and nonlinear effects. A total of 43 COPD diagnosed patients are evaluated, distributed as GOLD II (18), GOLD III (15) and GOLD IV (10). Experimental data supports the claims and indicate that the proposed model and index for nonlinearity is well-suited to capture COPD structural changes.

In their letter-to-the-editor entitled “Misconceptions of pathophysiology of happy hypoxemia and implications for management of COVID-19”, Tobin et al. (Respir Res 21:249, 2020) debated our views on happy hypoxemia in COVID-19 (Respir Res 21:198, 2020). We thank the authors for their interesting comments and alternative viewpoints, and we would like to clarify several important aspects raised.

High quality hospital care for serious ill persons requires exemplary team-based communication and decision-making. However, there is a need for evidence-based interventions in this area. This study's aim is to gain insight in the adoption and implementation of the COaching Doctors to improve Ethical decision-making (CODE) intervention, composed of one-on-one professional coaching in doctors and an alert to identify patients potentially receiving excessive treatment. Mixed-method process evaluation study using focus group interviews, sub-analysis of the ethical decision-making climate questionnaire (EDMCQ) in nurses and doctors and a satisfaction survey in doctors. Of the 423 clinicians, 198 (60.2%) nurses and 63 (67.0%) doctors filled-out the EDMCQ and 20 nurses and 12 doctors participated to the focus-group interviews respectively. Thirty-five (70%) of the 50 coached doctors filled-out the satisfaction survey. Doctors estimated their leadership skills higher than the nurses prior to the study period (P = 0.006) but no longer after the study period (P = 0.366). Nurses estimated ethical awareness and reflection higher (respectively, P = 0.002 and P = 0.049) and non-avoiding end-of-life decisions and active involvement of nurses lower than the doctors (respectively P < 0.001 and P = 0.023) after the study period but not before the study period (all P-values >0.05). Doctors testified of increased awareness in ethical decision-making, more open interactions with patients and nurses, and more courage to intervene instead of doing nothing. Nurses spoke of an increased awareness to act as patient advocate, increased deliberation among peer nurses and frustration when they felt no effect of activating the CODE alert. Both doctors and nurses advised for more active involvement of nurses. The mean overall satisfaction score in doctors was 8.69 on 10. The CODE study intervention was effective in raising awareness and self-reflection, yet did not succeed to close the (communication) gap between doctors and nurses in team-based ethical decision-making. ClinicalTrials.gov identifier: NCT05167019.

Background: Tiotropium + olodaterol has demonstrated improvements beyond lung function benefits in a large Phase III clinical program as a once-daily maintenance treatment for COPD and may be a potential option for the initiation of maintenance treatment in COPD. Despite guideline recommendations that combined long-acting β2-agonists and inhaled corticosteroids should only be used in individuals at high risk of exacerbation, there is substantial use in individuals at lower risk. This raises the question of the comparative effectiveness of this combination as maintenance treatment in this group compared to other combination regimens. Objective: The study aimed to assess the effect on lung function of once-daily tiotropium + olodaterol versus twice-daily salmeterol + fluticasone propionate in all participants with Global initiative for chronic Obstructive Lung Disease 2 or 3 (moderate to severe) COPD. Methods: This was a randomized, double-blind, double-dummy, four-treatment, complete crossover study in which participants received once-daily tiotropium + olodaterol (5/5 µg and 2.5/5 µg) via Respimat® and twice-daily salmeterol + fluticasone propionate (50/500 µg and 50/250 µg) via Accuhaler® for 6 weeks. The primary end point was change in forced expiratory volume in 1 second (FEV1) area under the curve from 0 hour to 12 hours (AUC0–12) relative to the baseline after 6 weeks. Results: Tiotropium + olodaterol 5/5 µg and 2.5/5 µg demonstrated statistically significant improvements in FEV1 AUC0–12 compared to salmeterol + fluticasone propionate (improvements from baseline were 317 mL and 295 mL with tiotropium + olodaterol 5/5 µg and 2.5/5 µg, and 188 mL and 192 mL with salmeterol + fluticasone propionate 50/500 µg and 50/250 µg, respectively). Tiotropium + olodaterol was superior to salmeterol + fluticasone propionate in lung function secondary end points, including FEV1 area under the curve from 0 hour to 24 hours (AUC0–24). Conclusion: Once-daily tiotropium + olodaterol in participants with moderate-to-severe COPD provided superior lung function improvements to twice-daily salmeterol + fluticasone propionate. Dual bronchodilation can be considered to optimize lung function in individuals requiring maintenance treatment for COPD.

Background Functional status is a marker for evaluating fall risk and predicting mortality and hospitalisations in elderly and patients with COPD. Acute exacerbations of COPD result in sudden declines in exercise capacity, quadriceps force (QF) and physical activity (PA), but their impact on functional status remains unclear. This study aimed to (i) compare the functional status of patients with COPD to healthy controls and (ii) assess prospectively the impact of an exacerbation on functional status. Methods Healthy controls and patients were assessed. Patients were followed up every 6 months and were tested again immediately if they reported an exacerbation. The short physical performance battery (SPPB), timed up and go test (TUG), 1-minute sit-to-stand test (1MSTS), 6-minute walking distance (6MWD), QF and PA (accelerometery) were measured. Results Thirty-six patients (69 ± 7 years, 69% male) and 25 matched healthy controls (68 ± 7 years, 80% male) were included. Functional status was decreased in patients compared to healthy controls. Twelve patients were retested 10 ± 7 days after a moderate (n = 11) or severe (n = 1) exacerbation. The 1MSTS (∆-3 ± 3repetitions, p < 0.0001), 6MWD (∆-34 ± 46m, p < 0.0001) and QF (∆-9 ± 13Nm, p = 0.05) decreased after exacerbation onset. No changes in SPPB and PA were observed. Conclusion An exacerbation negatively impacts the already reduced functional status in patients with COPD. The SPPB is not able to capture this decline.

Background: Patients with early-stage (I–IIIA) resectable non-small cell lung cancer (NSCLC) often experience reduced physical activity (PA) after surgery. PA telecoaching may support a more active lifestyle, but evidence in this population is limited. Objective: To evaluate acceptability, feasibility, safety, and actual usage of an automated and manual PA telecoaching program following surgery for NSCLC. Methods: In this multicenter, single-blind study, patients received either an eight-week automated coaching program (ACP) with a customized smartphone app or a manual coaching program (MCP) with weekly phone calls from a coach. Both groups used an activity tracker, linked to their smartphone, to monitor steps and receive feedback. Primary outcomes included acceptability, feasibility, safety and usage, assessed via questionnaires and interviews. Secondary outcomes included objectively measured PA (accelerometry), functional exercise capacity (six-minute walk distance) and symptoms (dyspnea, fatigue) and quality of life, evaluated via questionnaires. Results: Nineteen patients (12 males; 68 ± 6 years; baseline daily steps 7820 ± 2799) were included. The majority (18/19) found the intervention enjoyable, and a minority (6/19) reported minor smartphone issues. All patients wore the activity tracker consistently. No adverse events occurred. The ACP required significantly less coach contact time compared to the MCP (25 ± 14 vs. 54 ± 15 min, p = 0.0003). No other differences in primary outcomes were observed between groups. Changes in secondary outcomes were limited in both groups. Conclusion: PA telecoaching is feasible, well accepted, and safe in patients with NSCLC post-surgery, with excellent activity tracker adherence. The ACP required less coach involvement. However, increasing PA remains challenging, and no conclusions can be made about the effectiveness of telecoaching. Future research should explore longer interventions in larger populations to assess efficacy and long-term outcomes.

Research suggests that palliative home care should be integrated early into standard care for end-stage COPD patients. Patients also express the wish to be cared for and to die at home. However, a practice model for early integration of palliative home care (PHC) into standard care for end-stage COPD has not been fully developed. To develop an intervention for early integration of PHC into standard care for end-stage COPD patients. We conducted a Phase 0-I study according to the Medical Research Council Framework for the development of complex interventions. Phase 0 aimed to identify the inclusion criteria and key components of the intervention by way of an explorative literature search of interventions, expert consultations, and seven focus groups with general practitioners and community nurses on perceived barriers to and facilitators of early integrated PHC for COPD. In Phase 1, the intervention, its inclusion criteria and its components were developed and further refined by an expert panel and two expert opinions. Phase 0 resulted in identification of inclusion criteria and components from existing interventions, and barriers to and facilitators of early integration of PHC for end-stage COPD. Based on these findings, a nurse-led intervention was developed in Phase I consisting of training for PHC nurses in symptom recognition and physical therapy exercises for end-stage COPD, regular visits by PHC nurses at the patients' homes, two information leaflets on self-management, a semi-structured protocol and follow-up plan to record the outcomes of the home visits, and integration of care by enabling collaboration and communication between home and hospital-based professional caregivers. This Phase 0-I trial succeeded in developing a complex intervention for early integration of PHC for end-stage COPD. The use of three methods in Phase 0 gave reliable data on which to base inclusion criteria and components of the intervention. The preliminary effectiveness, feasibility and acceptability of the intervention will be subsequently tested in a Phase II study.

Evidence and guidelines are becoming increasingly clear about imbalance between the risks and benefits of inhaled corticosteroids (ICSs) in patients with COPD. While selected patients may benefit from ICS-containing regimens, ICSs are often inappropriately prescribed with - according to Belgian market research data - up to 70% of patients in current practice receiving ICSs, usually as a fixed combination with a long-acting β -adrenoreceptor agonist. Studies and recommendations support withdrawal of ICSs in a large group of patients with COPD. However, historical habits appear difficult to change even in the light of recent scientific evidence. We have built a collaborative educational platform with chest physicians and primary care physicians to increase awareness and provide guidance and support in this matter.

Consumer-based wearables are becoming more popular and provide opportunities to track individual's clinical parameters remotely. However, literature about their criterion and known-groups validity is scarce. This study aimed to assess the validity of the Fitbit Charge 4, a wrist-worn consumer-based wearable, to measure clinical parameters (ie, daily step count, resting heart rate [RHR], heart rate variability [HRV], respiratory rate [RR], and oxygen saturation) in patients with chronic obstructive pulmonary disease (COPD) and healthy controls in free-living conditions in Belgium by comparing it with medical-grade devices. Participants wore the Fitbit Charge 4 along with three medical-grade devices: (1) Dynaport MoveMonitor for 7 days, retrieving daily step count; (2) Polar H10 for 5 days, retrieving RHR, HRV, and RR; and (3) Nonin WristOX2 3150 for 4 nights, retrieving oxygen saturation. Criterion validity was assessed by investigating the agreement between day-by-day measures of the Fitbit Charge 4 and the corresponding reference devices. Known-groups validity was assessed by comparing patients with COPD and healthy controls. Data of 30 patients with COPD and 25 age- and gender-matched healthy controls resulted in good agreement between the Fitbit Charge 4 and the corresponding reference device for measuring daily step count (intraclass correlation coefficient [ICC2,1]=0.79 and ICC2,1=0.85, respectively), RHR (ICC2,1=0.80 and ICC2,1=0.79, respectively), and RR (ICC2,1=0.84 and ICC2,1=0.77, respectively). The agreement for HRV was moderate (healthy controls: ICC2,1=0.69) to strong (COPD: ICC2,1=0.87). The agreement in measuring oxygen saturation in patients with COPD was poor (ICC2,1=0.32). The Fitbit device overestimated the daily step count and underestimated HRV in both groups. While RHR and RR were overestimated in healthy controls, no difference was observed in patients with COPD. Oxygen saturation was overestimated in patients with COPD. The Fitbit Charge 4 detected significant differences in daily step count, RHR, and RR between patients with COPD and healthy controls, similar to those identified by the reference devices, supporting known-groups validity. Although the Fitbit Charge 4 shows mainly moderate to good agreement, measures of clinical parameters deviated from the reference devices, indicating that monitoring patients remotely and interpreting parameters requires caution. Differences in clinical parameters between patients with COPD and healthy controls that were measured by the reference devices were all detected by the Fitbit Charge 4.